Background: Tuberculosis (TB) remains one of the top health problems in Ethiopia, and over one-third of estimated TB cases remain undetected. This study examined the magnitude and factors of missed opportunities for TB investigation at public health facilities in Northwest Ethiopia. Methods: A facility-based cross-sectional study was conducted among 412 adult patients with TB symptoms from 34 randomly selected public health facilities. Data on socio-demographics, TB symptoms, and clinical status were collected by an exit interview. A patient was considered missed for TB investigation if he/she had at least one symptom suggestive of TB but did not receive a sputum smear and/or x-ray evaluation to rule out TB. We computed descriptive and analytical statistics using SPSS version 26. A negative binomial regression analysis was used to identify factors associated with missed opportunities for TB investigation. Statistical significance was determined at a p-value less than 0.05. Results: A total of 412 presumptive TB patients, 235 (57%) females and 247 (60%) rural dwellers were interviewed. The mean age of respondents was 35 ± 8 years and 228 (55.3%) were from health centers. Over two-thirds, 284 (69%) were new patients, 62 (15%) were HIV positive and 78 (19%) had diabetes mellitus (DM). Fifty patients with symptoms suggestive of TB did not receive sputum evaluation services. Inability to read and write, having DM, having normal body mass index and facility type they visited were significant factors to missing opportunities to get TB investigations. Conclusion: A significant number of patients with symptoms suggestive of TB were missed for sputum evaluation to rule out TB. Education level, comorbidity, nutritional status and type of facility patients attended were factors of missing opportunities for TB investigation. Thus, improving quality of TB diagnosis, screening TB among all types of patients, and paying attention to screen illiterate people are crucial to avoid missing potential TB cases.
From January to April 2020, a multicenter facility-based cross-sectional study was conducted on 412 adults aged 18 and up who presented with symptoms suggestive of TB according to WHO criteria.19 The research was carried out in the East Gojjam Zone, one of the 15 zones that comprise the Amhara Regional State in Northwest Ethiopia. In 2019, the zone’s estimated population is 2,740,625 people, with approximately 85% of them living in rural areas. The zone spans 14,010 km2 and is divided into 19 administrative woredas (a third-level administrative hierarchy in Ethiopia). At the time of data collection, it had 517 public health facilities (406 health posts, 102 health centers, and nine hospitals). TB prevention and control activities are carried out in accordance with the national and WHO TB diagnosis and treatment manuals.19 Sputum smear microscopy is the primary TB diagnostic tool in all health facilities, and X-ray service is only available in hospitals as a backup TB diagnostic tool. All patients receive free TB diagnosis and treatment.16 Because health posts only provide TB prevention and treatment follow-up,19 only health centers (HCs) and hospitals are included in this study (Figure 1). Diagram of sampling flow for missed opportunities of PTB cases in East Gojjam Zone, 2020. The source population for this study was all patients visiting 34 randomly selected public health facilities to seek healthcare services. The study population consisted of all patients aged 18 and up who visited the outpatient (OPD), anti-retroviral treatment (ART), and maternal and child health (MCH) units of those health facilities. Patients who had at least one symptom suggestive of TB according to WHO18 and Ethiopian national TB diagnosis and treatment criteria16 (cough for 2 weeks or more, night sweats, unexplained weight loss, fever for more than 2 weeks, fatigue, loss of appetite, and bloody sputum) were included in the study. Furthermore, for people on ART, we included patients with any duration of cough because HIV is a risk factor for Active TB infection due to a decline in human immune status.12 Patients who already gave sputum/chest X-ray for TB examination were excluded from the study. Accordingly, a patient who had at least one symptom suggestive of TB but did not receive sputum and/or x-ray evaluation to rule out TB was considered a missed opportunity for TB investigation. The sample size (412) was calculated by Epi Info version 7 using a 95% confidence interval (CI), a 5% margin of error, a 42% proportion of patients with symptoms suggestive of TB, but not ruled out for TB17 and a 10% non-response rate. Due to time and resource constraints, we only used 30% of the 102 health centers and nine hospitals as study sites. As a result, we used a lottery to select 31 health centers and three hospitals. Then, all patients over the age of 18 from 34 health facilities with symptoms suggestive of TB were included in the study (Figure 1). An exit interview was conducted by six trained data collectors (nurses and health officers) and three master-holder public health practitioners (supervisors). A structured questionnaire administered by an interviewer was used to collect data on demographics, TB symptoms, and other clinical data relevant to TB. Participants in the study were also asked if they had requested sputum and/or x-ray examination by healthcare workers for TB diagnosis during that visit. If sputum microscopy and/or x-ray were not requested, they were referred back to OPD for appropriate TB investigations. Because there was no access to culture and GeneXpert services during data collection, patients with suggestive TB symptoms were evaluated by sputum smear microscopy and chest X-ray. The diagnostic test procedures were carried out based on the Ethiopian National TB Diagnosis Guidelines adapted from the WHO TB Diagnosis Guidelines19,20 (Figure 2). Ethiopian national diagnostic algorithms for patients with presumptive TB, 2020. The questionnaire was pretested in public health facilities with similar settings but not on study sites. Following two days of training, data collectors and supervisors participated in data collection. The data collector was closely supervised and supported by the principal investigator and supervisors. Data completeness and consistency were checked daily, with possible feedback to data collectors. Statistical Analysis for Social Sciences (SPSS) version 26 was used to enter, clean, and analyze the data. Various descriptive statistics, such as means and medians for continuous variables and frequencies and percentages for categorical variables, were computed. The proportion of missed opportunities for TB investigation was calculated by dividing the number of patients with TB symptoms who did not receive sputum and/or x-ray evaluations to rule out TB by the total number of patients with TB symptoms. Since the outcome variable was the number of missed opportunities for TB investigation (count data), we first proposed a Poisson regression analysis. The assumption checking step, on the other hand, revealed that the data were over-dispersed, with a deviation to the degree of freedom ratio of greater than one. As a result, we used bivariate and multivariable negative binomial regression analysis to find factors linked to the missed TB research opportunity, and control confounding effects, respectively. Steps with the lowest Akaike’s Information Criteria and Bayesian Information Criteria values were followed throughout the data analysis. As a result, a negative binomial regression analysis was carried out by selecting a “custom tab” from the model window type. We utilized a negative binomial model from the “Distribution” options, log from the connection function, and the “Estimate values” button in this stage. The statistical significance was determined at p-values <0.05, and the association was described using an adjusted incidence rate ratio (AIRR) at a 95% confidence interval (CI) (Table 1). Factors Associated with Missing to Get TB Diagnostics in East Gojjam Zone, Northwest Ethiopia, 2020 (N = 412) Abbreviations: CIRR, crude incidence rate ratio; AIRR, adjusted incidence rate ratio. The study was conducted according to the principles of the Declaration of Helsinki and fulfilled the Ethiopian National Health Research and Ethics Guideline. The ethical review committee of Bahir Dar University’s College of Medicine and Health Sciences approved the study protocol and gave ethical clearance (Protocol No: 091/18-04). The Amhara Regional Health Bureau and the East Gojjam Zone Health Department both sent letters of support. Prior to data collection, managers of district health offices and health facilities were contacted and informed. All study participants provided informed consent, and participation was entirely voluntary. Data confidentiality was ensured by removing personal identifiers from the data and restricting it with a password. All patients who tested positive for TB were referred to TB clinics for anti-TB treatment monitoring and HIV screening. Families of TB positive cases were advised to visit health facilities to check their TB status.
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